The impact of opioid prescribing report cards in Medicaid

BACKGROUND: Performance feedback has been used for decades to improve health care quality and safety, with varying degrees of success. One example is the use of customized report cards that target inappropriate prescribing of high-risk medications, including opioids. Randomized controlled trials suggest that report cards are an effective tool to change opioid prescribing behavior, but their effectiveness in community settings is unclear. OBJECTIVE: To evaluate the impact of opioid prescribing report cards, which were mailed to Medicaid providers in Philadelphia, Pennsylvania. METHODS: Using a quasi-experimental approach, we compared trends in opioid prescribing by Medicaid providers in Philadelphia, who received a report card in late 2017, with Medicaid providers in surrounding counties, who did not receive report cards. First, we used propensity score matching to balance observed differences in the treatment and comparison groups; matching variables included provider specialty, sex, and selected characteristics of providers’ Medicaid patient panels. We then estimated a difference-in-differences model to isolate the impact of report cards on opioid prescribing. RESULTS: The analytical sample included 1,598 providers in Philadelphia and 2,117 providers in surrounding counties, who prescribed opioids to 99,548 Medicaid patients during the study period. Although the number of Medicaid patients receiving opioids and the days supplied of opioids declined in both Philadelphia and surrounding counties during the study period, there was a larger reduction in Philadelphia Medicaid than in surrounding counties after the report cards were mailed. In the 6 months after the report cards were mailed (January 2018 to June 2018) compared with the 6 months before they were mailed (July 2017 to December 2017), we estimate that the reduction in opioid prescribing in Philadelphia Medicaid amounted to nearly 3 fewer Medicaid patients with an opioid prescription per month. CONCLUSIONS: After customized opioid prescribing report cards were mailed to Medicaid providers in Philadelphia, Pennsylvania, there was a statistically significant reduction in opioid prescribing to Medicaid patients relative to surrounding counties. Our findings suggest that opioid prescribing report cards with peer comparison are an effective way to influence opioid prescribing behavior among Medicaid providers. Report cards can complement other initiatives that target inappropriate opioid prescribing, such as prescription drug monitoring programs and prior authorization.


Plain language summary
High levels of opioid prescribing can be dangerous for patients. Report cards that describe a doctor's opioid prescribing, including whether they prescribe more opioids than other doctors, could help reduce opioid prescribing. In 2017, we mailed report cards to doctors in Philadelphia, Pennsylvania, which included the number of patients to whom they prescribed opioids. We found that doctors prescribed fewer opioids after they received the report card.

Implications for managed care pharmacy
Our results suggest that report cards with peer comparison are one way to effectively address problematic prescribing behavior. Although opioid prescribing report cards have been used by states in conjunction with prescription drug monitoring programs, we further demonstrate how managed care organizations can implement performance feedback initiatives for populations that have been disproportionately affected by the opioid epidemic.
Reducing inappropriate opioid prescribing is a top priority of Medicaid programs, whose population has been disproportionately affected by the opioid epidemic. 1,2 According to one study, 28% of Medicaid patients had at least 1 visit with a pain-related indication in 2017, and more than 35% of these patients had at least 1 opioid prescription, placing them at increased risk of developing an opioid use disorder. 3,4 One way to discourage inappropriate care delivery is through performance feedback. [5][6][7] Studies have shown that performance feedback can be effective at changing provider behavior, although its impact depends on providers' baseline performance, the source and duration of the feedback, and the use of peer comparison. [8][9][10] A common type of performance feedback is customized report cards. Prior to the opioid epidemic, report card interventions often focused on antibiotic and antipsychotic prescribing. 11,12 In response to the opioid epidemic, report cards have begun focusing on opioid prescribing. Although studies have demonstrated their effectiveness, they have been small in scale and occurred in individual practices or emergency departments. [13][14][15] A notable exception is the larger-scale randomized trial that included more than 400 clinicians across 48 emergency departments and urgent care settings, which recently demonstrated that report cards can effectively reduce opioid prescribing. 16 Some states, including Arizona, Kentucky, and Ohio, introduced opioid prescribing report cards in conjunction with their prescription drug monitoring programs (PDMPs), but it is unclear whether these efforts affected opioid prescribing in community settings. 17,18 In states where Medicaid is operated at the county level, there may be opportunities to introduce and evaluate report cards in community settings. This occurred in Philadelphia, Pennsylvania, which is among the worst-hit municipalities in terms of opioid dependence, overdoses, and mortality. 19 In 2017, a multidisciplinary team of county officials, Medicaid managed care organizations, and academics developed and mailed opioid prescribing report cards to more than 2,000 Medicaid providers, presenting a unique opportunity to study the effectiveness of these report cards using quasiexperimental methods. 20 To our knowledge, it was the first opioid prescribing report card launched by a county-level collaborative.
Here, we evaluate the effectiveness of the opioid prescribing report card by comparing opioid prescribing by Philadelphia Medicaid providers with the opioid prescribing of a matched cohort of Medicaid providers from 8 neighboring Pennsylvania counties, who did not receive report cards. We used propensity score matching to balance baseline differences in Philadelphia vs surrounding counties, including provider specialty, sex, and selected characteristics of their Medicaid patient panel. We then employed a differencein-differences model to isolate the change in the number of Medicaid patients receiving an opioid prescription and the days supplied of opioid prescriptions attributable to the report card.

Methods
This research has been conducted in compliance with applicable federal and state research and privacy laws and was exempted by the University of Pittsburgh's Institutional Review Board.

REPORT CARD DESIGN AND IMPLEMENTATION
In 2017, Community Behavioral Health, which is Philadelphia's only designated Medicaid behavioral health managed care organization, collaborated with 4 Medicaid physical health managed care organizations, the Philadelphia Department of Public Health, and the University of Pennsylvania to implement opioid prescribing report cards. Community Behavioral Health organized the effort because, as the sole behavioral health managed care organization in Philadelphia County, it had access to pharmacy claims for the entire Medicaid population, which included more than 700,000 beneficiaries.
Report cards detailed aggregate opioid prescribing measures for the provider's Medicaid patients and included peer comparison within providers' specialty type. Within specialties, providers were ranked as normal, high, severe, and extreme based on the number of SDs above the mean and the days supplied of opioids declined in both Philadelphia and surrounding counties during the study period, there was a larger reduction in Philadelphia Medicaid than in surrounding counties after the report cards were mailed. In the 6 months after the report cards were mailed (January 2018 to June 2018) compared with the 6 months before they were mailed (July 2017 to December 2017), we estimate that the reduction in opioid prescribing in Philadelphia Medicaid amounted to nearly 3 fewer Medicaid patients with an opioid prescription per month.

CONCLUSIONS:
After customized opioid prescribing report cards were mailed to Medicaid providers in Philadelphia, Pennsylvania, there was a statistically significant reduction in opioid prescribing to Medicaid patients relative to surrounding counties. Our findings suggest that opioid prescribing report cards with peer comparison are an effective way to influence opioid prescribing behavior among Medicaid providers. Report cards can complement other initiatives that target inappropriate opioid prescribing, such as prescription drug monitoring programs and prior authorization.
during the baseline period (July 1, 2016, through June 30, 2017); providers who prescribed opioids to fewer than 10 patients were still included in the construction of peer comparison. The opioid prescribing report cards used 12 months of pharmacy claims from the baseline period and were mailed in December 2017. More detail on the implementation of the report card, including the development of measures, is available elsewhere. 19

STUDY SAMPLE
The treatment group comprised 2,289 Medicaid providers in Philadelphia who were mailed a customized report card. The comparison group comprised 3,470 Medicaid providers from 8 surrounding counties (Berks, Bucks, Chester, Delaware, Montgomery, Northampton, Lehigh, and Lancaster Counties), who met the same criteria used by Philadelphia (ie, they prescribed opioids to 10 or more patients during the study period) but did not receive a report card. We excluded any provider from a surrounding county that also treated a Philadelphia Medicaid patient and required Medicaid providers to have a National Provider Identifier present in Medicaid claims for linking provider characteristics (Supplementary Figure 1, available in online article).

DATA SOURCES
Report card measures were constructed using Medicaid pharmacy claims and were aggregated to the provider level using their National Provider Identifier. Opioid prescriptions were identified using national drug codes. 21 The Medicaid enrollment file was used to identify patient demographics, including age, sex, race and ethnicity, and county of residence. Medicaid claims containing procedure codes, diagnoses, and service dates were used to construct other relevant characteristics, including an tapering. Mailings also included a reminder to access Pennsylvania's PDMP when prescribing opioids to view recent opioid prescriptions for individual patients.
Providers received report cards only if they prescribed opioids to 10 or more Philadelphia Medicaid patients for the number of Medicaid patients with at least 1 opioid prescription fill and the total days supplied of opioid prescription fills. To encourage recommended best practices, the report card mailings included additional documentation of evidence-based clinical guidelines for opioid prescribing and Race and ethnicity were not included in the final propensity score-matching model owing to baseline differences but were controlled for in the difference-in-differences estimation. well as provider specialty type and sex. We then calculated standardized differences of covariates between the treatment and comparison groups. We used 0.10 as the cutoff for which characteristics were included and excluded from the propensity score matching, which is consistent with best practices. 23 Finally, we conducted a difference-in-differences analysis using generalized estimating equations with negative Elixhauser index, which measured the severity of medical conditions, and the share of patients with a diagnosed mental illness and severe mental illness. A Medicaid provider file, maintained by the Pennsylvania Department of Human Services, included information on provider specialty type and sex.

STATISTICAL ANALYSIS
We assessed the number of Medicaid patients per provider receiving an opioid prescription and the days supplied of opioid prescriptions per provider during a 6-month preperiod (

Results
The initial study sample comprised 2,289 providers in Philadelphia and 3,470 providers in surrounding counties ( Table 1). The most frequent provider type was primary care physicians, followed by emergency medicine physicians and advanced practitioners, including nurse practitioners and physician assistants. In total, our sample of providers treated 1,199,630 Medicaid patients and prescribed opioids to 99,548 Medicaid patients between July 1, 2016, and June 30, 2017. On average, providers in Philadelphia treated more Medicaid patients than providers in surrounding counties: 549 in Philadelphia compared with 449 in surrounding counties.
After exclusion criteria and propensity score matching, the study sample comprised 1,598 providers in Philadelphia and 2,117 providers in surrounding counties. There were no significant differences in the number of Medicaid patients, binomial distributions to isolate the effectiveness of the report cards, comparing opioid prescribing from the preperiod to the postperiod. 24 We converted the coefficients into incidence rate ratios (IRRs) for interpretability. IRRs represent the impact of a given independent variable as a percent change in the dependent variable; an IRR above 1 indicates an increased risk, whereas an IRR below 1 indicates a decreased risk.
Because patient race and ethnicity did not meet the 0.10 cutoff in standardized differences, we excluded those characteristics from the propensity score matching (Supplementary Figure 2). However, we adjusted for patient race and ethnicity in the difference-in-differences analysis.
The Elixhauser index was included in both the propensity score matching and the difference-in-differences analysis, which is considered a "doubly robust" approach given were prescribing opioids to 9.7 Medicaid patients on average whereas providers in surrounding counties prescribed opioids to 5.0 Medicaid patients on average. By December 2017, the month that opioid prescribing report cards were mailed out, Philadelphia providers were prescribing opioids to 7.6 Medicaid patients on average compared with 3.8 Medicaid patients in the comparison group. After accounting for pretrends and adjusting for race and ethnicity using difference-in-differences estimation, we found a significantly larger decline in the number of Medicaid patients in Philadelphia receiving opioid prescriptions relative to surrounding counties in the postperiod (IRR = 0.88; 95% CI = 0.83-0.93; Table 2). In the Philadelphia cohort, the number of Medicaid patients decreased by 29% (IRR Postperiod × IRR Interaction ) in the postperiod, larger than 19% (IRR Postperiod ) in the comparison cohort. According to marginal effects estimated from the adjusted difference-indifferences models, the number of Medicaid patients with an opioid prescription declined by 4.0 per month between the preperiod and postperiod in the Philadelphia cohort. In the comparison group, the estimated decline was 1.2 Medicaid patients per month. Per provider, the differential decline between the treatment and comparison groups was therefore estimated to be 2.8 Medicaid patients with an opioid prescription per month.
We also found a greater reduction in the days supplied of opioid prescriptions in the Philadelphia cohort (IRR = 0.85; 95% CI = 0.78-0.92). The differential decline between the treatment and comparison groups was 66.1 days supplied of opioids per month per provider.
Of note, there was a statistically significant relationship between the racial composition of patients and some opioid prescribing outcomes. For example, a larger share of Black patients was associated with fewer opioid prescriptions (IRR = 0.65; 95% CI = 0.45-0.93). However, this relationship did not apply to the number of days supplied of opioid prescriptions (IRR = 1.04; 95% CI = 0.35-3.06).

Discussion
The opioid epidemic has resulted in myriad practice and policy initiatives, and opioid prescribing is now dropping precipitously throughout the United States. 26 Yet concerns about the appropriateness of opioid prescribing remain, with more than 150 million opioid prescriptions written in 2019 and opioid overdose deaths spiking in 2020. 27,28 In Philadelphia, which ranked second in overdose deaths among 44 counties with a million residents in 2016, report cards were mailed to Medicaid providers in late 2017 to reduce excessive opioid prescribing. 19,20 In this quasi-experimental study, we found that report cards resulted in a the share of female patients, the share of patients with a mental illness or severe mental illness, or provider type after matching. Because differences persisted in the racial and ethnic composition of patient panels (eg, 55% of Medicaid patients in Philadelphia were Black compared with only 16% of patients in surrounding counties), race and ethnicity were not included in the final propensity score-matching model.
There was a large decline in opioid prescribing in both the treatment and comparison groups that predated the release of the report cards-the pretrend occurred for both the number of Medicaid patients with an opioid prescription ( Figure 1) and the days supplied of opioid prescriptions (Figure 2). In July 2017, Philadelphia providers  TABLE 2 and surrounding counties would have been on the same trajectory in opioid prescribing in the absence of the report cards, which cannot be verified using retrospective data. 34 Another limitation is that the Medicaid population was from a particular region of the country and may not be representative of other Medicaid populations. Although Medicaid patients have been disproportionately affected by the opioid epidemic, a more complete picture of the effectiveness of opioid prescribing report cards would include patients with Medicare or private insurance. Finally, there may be potential spillover effects to consider. Reductions in opioid prescribing could result in unintended consequences that warrant further scrutiny, especially if the reduction in opioid prescribing is differentially affecting patients with moderate to severe pain. 35

Conclusions
Combatting the opioid epidemic requires multiple approaches, and our results suggest that report cards can contribute to efforts to reduce opioid prescribing. Report cards can also give providers customized performance feedback and resources regarding opioid prescribing and tapering.

DISCLOSURES
Drs Candon and Rothbard and Ms Shen received funding from Community Behavioral Health in Philadelphia, Pennsylvania. Drs Xue, Cole, and Donohue received funding from Pennsylvania Department of Human Services. Neither Community Behavioral Health nor the Pennsylvania Department of Human Services was involved in the study design; collection, analysis, and interpretation of data; writing of the report; or the decision to submit the report for publication. literature on performance feedback by expanding the evidence of report cards' effectiveness outside of the confines of a randomized controlled trial using a large sample of patients who were enrolled in Medicaid.
This study also serves as an example of a successful community quality collaborative-it was developed by county-level Medicaid managed care organizations in collaboration with local stakeholders rather than by a state or individual health system. 32 Report cards are low-cost and educational, and similar approaches could be introduced in counties with high rates of opioid overdoses and mortality in cases where the state or federal government are not able to implement evidence-based interventions in a timely manner.

LIMITATIONS
Constructing an appropriate comparison group for this study was a challenge given the racial and ethnic differences in the Medicaid population in Philadelphia vs the surrounding counties. Because patients' race and ethnicity has been shown to be an important factor in opioid prescribing, we initially used them in our matching methods. Differences between the treatment and comparison group remained after matching, as shown by the standardized differences, so we excluded them from the matching and instead used race and ethnicity as a covariate in the difference-in-differences estimation. 33 Other sociodemographic and cultural differences between Philadelphia and surrounding counties, such as population density, may contribute to trends in opioid prescribing and were not adjusted for in our estimation. We also note that difference-in-differences estimation is susceptible to between-group differences and relies on an assumption that Philadelphia statistically significant decline in opioid prescribing to Medicaid patients in Philadelphia relative to surrounding counties.
There were other policy changes that may have contributed to the decline in opioid prescribing. Like most states, Pennsylvania launched a PDMP, allowing providers to track patients with opioid prescriptions. 29 The PDMP was a state-level intervention introduced in 2016 that affected the treatment and comparison groups similarly. The Centers for Disease Control and Prevention implemented guidelines on opioid prescribing during this period, which may have also contributed to the reduction in opioid prescribing. As with the PDMP, these guidelines should have affected both the treatment and comparison groups. 30 Prior authorization policies, which require insurers' preapproval to prescribe certain prescriptions, likely contributed to the downward trends as well. 31 There are 4 Medicaid physical health managed care organizations in Philadelphia, which all introduced or expanded prior authorization before the introduction of report cards. Although the managed care organizations serving Philadelphia Medicaid patients also operate in the surrounding counties, there may have been some differences in the treatment and comparison groups as to when the prior authorization began.
The competing policy and practice initiatives surrounding opioid prescribing, as well as individualized efforts by health systems and other community organizations in Philadelphia, make it more difficult to isolate the effects of standalone interventions. However, our findings suggest that report cards contributed to the reduction in opioid prescribing to Philadelphia Medicaid patients. This study contributes to the broader